Male urethral strictures and their management

Design, Development, and Validation of a First, Low-cost, Three-dimensional (3D) Printed Optical Urethrotomy Simulation Model

OBJECTIVE

To develop and validate a low-cost, portable, and reusable simulation model for optical internal urethrotomy (OIU) training.

METHODS

A 3D-printed low-cost simulation model for OIU was designed locally and the final model was evaluated by trainees and trainers at the urology boot camps (UK, Belgium, Portugal, Poland). Participants were asked to complete a questionnaire, using a 6-item 5-point Likert Scale, to assess the model's anatomic realism.

RESULTS

A total of 27 trainees and 9 trainers evaluated the model. The model's anatomy and color were rated as the most realistic features, with 88.9% and 11.1% of respondents rating them as good and excellent, respectively. There were no significant differences between consultants and trainees in their assessment of any of the simulation properties of the OIU model.

CONCLUSION

Our study introduces an innovative, lifelike, and cost-effective simulation model for OIU training. Our model provides a realistic simulation of OIU. We feel that our low-cost and reusable model fills the gap in simulation-based training for young trainees in urology.

Early Post-Operative Events After Urethroplasty in Obese Patients: A Multi-Institutional Retrospective Series

OBJECTIVE

To compare early urethroplasty outcomes in non-obese, obese and morbidly obese patients undergoing urethroplasty for urethral stricture disease. The impact of obesity on outcomes is poorly understood but will be increasingly important as obesity continues to rise.

METHODS

Patients underwent urethroplasty at one of the 5 institutions between January 2016 and December 2020. Obese (BMI 30-39.9, n = 72) and morbidly obese (BMI >40, n = 49) patients were compared to normal weight (BMI <25, n = 29) and overweight (BMI 25-29.9, n = 51) patients. Demographics, comorbidities, and stricture characteristics were collected. Outcomes including complications, recurrence, and secondary interventions were compared using univariate and multivariate analysis.

RESULTS

Two hundred and one patients (Mean BMI 34.1, Range 18.4-65.2) with mean age 52.2 years (SD=17.2) were analyzed. Median follow-up time was 3.71 months. Obese patients were younger (P = .008), had more anterior (P <.001), iatrogenic and LS-associated strictures (P = .036). Sixty-day complication rate was 26.3% with no differences between cohorts (P = .788). Around 9.5% of patients had extravasation at catheter removal, 18.9% reported stricture recurrence, and 7.4% required additional interventions. Obese patients had greater estimated blood loss (P = .001) and length of stay (P = .001). On multivariate analysis, smoking associated with contrast leak (OR 7.176, 95% CI 1.13-45.5) but not recurrence or need for intervention (P = .155, .927).

CONCLUSION

Obese patients in our cohort had more anterior, iatrogenic, and LS-related strictures. However, obesity is not associated with complications, contrast leak, secondary interventions, or recurrence. Obese had higher blood loss and length of stay. Urethroplasty is safe and effective in obese patients.

Protein-based bioactive coatings: from nanoarchitectonics to applications

Protein-based bioactive coatings have emerged as a versatile and promising strategy for enhancing the performance and biocompatibility of diverse biomedical materials and devices. Through surface modification, these coatings confer novel biofunctional attributes, rendering the material highly bioactive. Their widespread adoption across various domains in recent years underscores their importance. This review systematically elucidates the behavior of protein-based bioactive coatings in organisms and expounds on their underlying mechanisms. Furthermore, it highlights notable advancements in artificial synthesis methodologies and their functional applications in vitro. A focal point is the delineation of assembly strategies employed in crafting protein-based bioactive coatings, which provides a guide for their expansion and sustained implementation. Finally, the current trends, challenges, and future directions of protein-based bioactive coatings are discussed.

Pharmacotherapy of urethral stricture

Urethral stricture is characterized by the chronic formation of fibrous tissue, leading to the narrowing of the urethral lumen. Despite the availability of various endoscopic treatments, the recurrence of urethral strictures remains a common challenge. Postsurgery pharmacotherapy targeting tissue fibrosis is a promising option for reducing recurrence rates. Although drugs cannot replace surgery, they can be used as adjuvant therapies to improve outcomes. In this regard, many drugs have been proposed based on the mechanisms underlying the pathophysiology of urethral stricture. Ongoing studies have obtained substantial progress in treating urethral strictures, highlighting the potential for improved drug effectiveness through appropriate clinical delivery methods. Therefore, this review summarizes the latest researches on the mechanisms related to the pathophysiology of urethral stricture and the drugs to provide a theoretical basis and new insights for the effective use and future advancements in drug therapy for urethral stricture.

Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis

BACKGROUND

Sexual function after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of nontransecting bulbar urethroplasty (ntBU) in terms of erectile dysfunction (ED).

AIM

This meta-analysis aimed to compare the efficacy and safety of ntBU with that of transecting bulbar urethroplasty (tBU).

METHODS

The PubMed, Web of Science, Cochrane, and Embase databases were searched and reviewed up to October 31, 2022. Quality evaluation was performed using the Newcastle-Ottawa scale system and Cochrane tools for the nonrandomized and randomized studies, respectively. Baseline characteristics, preoperative information, and postoperative outcomes were collected.

OUTCOMES

Outcomes included success rate, ED, overall complication, and maximum urinary flow.

RESULTS

Thirteen studies comprising 1683 patients met the inclusion criteria, with 596 and 1087 patients undergoing ntBU and tBU, respectively. The results revealed that compared with the tBU group, the patients who underwent ntBU had a significantly lower incidence of ED, while there were no significant differences in the other perioperative outcomes. In subgroup analysis, the nontransecting anastomotic urethroplasty group had a lower incidence of ED than excision and primary anastomosis, and other perioperative outcomes were similar between the 2 groups.

CLINICAL IMPLICATIONS

The results of the study may help clinicians choose procedures that protect sexual function in the treatment of urethral stricture.

STRENGTHS AND LIMITATIONS

The strength of this study is that it is, to our knowledge, the first meta-analysis to evaluate the efficacy and safety of ntBU. A limitation is that most of the included studies were retrospective cohort studies.

CONCLUSION

ntBU preserves the high efficacy of its transecting counterpart while reducing postoperative ED.

Development of male and female models of long urethral strictures in swine

Background

Preclinical animal models which mimic the dimensions of long urethral strictures (>2 cm in length) encountered in the clinic are necessary to evaluate prospective graft designs for urethroplasty. The purpose of this study was to develop both male and female porcine models of long urethral strictures (∼4 cm in length) and characterize histological and functional outcomes of iatrogenic stricture formation between genders.

Methods

Focal, partial thickness urethral injuries were created over 5-6 cm long segments in male and female swine (N = 4 per gender) via electrocoagulation and the degree of stricture formation was monitored for up to 6 weeks by urethroscopy and retrograde urethrography. Animals were sacrificed following stricture confirmation and histological, immunohistochemical, and histomorphometric analyses were performed on strictured and uninjured control urethral segments to profile wound healing responses.

Results

Urethral stricture formation was detected in all female swine by 2 weeks and 100 % of male swine at 3.2 ± 1.8 weeks, post-operatively. The mean length of urethral strictures in both male and female swine was ∼4 cm. Substantial variations in the degree of stricture severity between sexes were observed with males exhibiting significant urethral stenosis and loss of α-smooth muscle actin+ smooth muscle bundles in comparison to controls, while females primarily displayed defects in pan-cytokeratin+ epithelia as well as functional urethral obstruction.

Conclusions

Electrocoagulation injury is sufficient to produce long urethral strictures in male and female swine and the degree of stricture severity and nature of urethral obstruction was observed to be dependent on gender. Animal Protocol: AUP-19-150.

Key message

Novel male and female models of long urethral strictures in swine were created to characterize histological and functional outcomes of iatrogenic stricture formation between genders.

Management and outcomes of urethral stricture: single centre experience over 13 years

AIM

To present a comprehensive summary of the diagnosis, treatment and follow-up process of patients who underwent open urethroplasty in our tertiary referral center for the treatment of urethral stricture in the last 13 years.

MATERIALS AND METHODS

Two hundred and forty-five (245) patients who underwent open urethroplasty between January 2008 and June 2021 were retrospectively analysed. Detailed history, physical examination, uroflowmetry, retrograde urethrography and/or voiding cystourethrography and/or urethroscopy were used throughout the preoperative diagnosis process. While evaluating the postoperative patency rates, the absence of preoperative voiding symptoms after the operation and Qmax 15 ml/sec and above were taken into account.

RESULTS

Mean stricture length was 3.8 +/- 1.4 cm. Transurethral endoscopic interventions in 79 patients (32.2%), catheterisation in 55 patients (22.4%), trauma in 54 patients (22%), infection in 15 patients (6.2%), and idiopathology in 42 patients (17.2%) were the causes for the stricture. Buccal mucosal graft was used in 125 patients (51%), penile skin flap in 32 patients (13%), end-to-end anastomosis in 83 patients (33.8%) and Heineke-Mikulicz technique in 5 patients (2%). Mean follow-up period was 67.1 +/- 28.9 months. Success rates of patients were 84% (105) in buccal mucosal graft, 78.1% (25) in penile skin flap, 86.7% (72) with end-to-end anastomosis and 80% (4) with Heineke-Mikulicz technique.

CONCLUSION

Among treatment options for urethral stricture, urethroplasty techniques is the most successful treatment. Consideration of the factors leading to the formation of the stricture, with the intraoperative findings and surgical experience will maximize the benefit the patient receives.

Progressive urethral dilation in male horses undergoing perineal urethrotomy for cystolith removal: 22 cases

This retrospective case series describes the use of progressive urethral dilation in 22 client-owned male horses undergoing perineal urethrotomy (PU) for cystolith removal. Medical records of horses undergoing PU and urethral dilation for treatment of cystolithiasis were reviewed. Dilation of the pelvic urethra was performed following PU and using customized dilators with the same length (30cm) and with various outer diameters (25 to 45mm). Analyzed data included: signalment, cystolith size, renal ultrasound findings, method used for cystolith removal, diameter of urethral dilators, intra- and post-operative complications, and hospitalization time. Cystolith size ranged between 37mm and 90mm. Dilation of the pelvic urethra was as follows: 35mm (n=8), 25mm (n=6), 39mm (n=3), 33mm (n=2), 28mm (n=2) and 45mm (n=1). In 6 cases, the cystolith was removed without fragmentation. In the remaining 16 horses, lithotripsy was performed with forceps (n=9) or a pneumatic scaler (n=7). In 15 horses a retrieval device was used to aid in calculi removal. Hospitalization time ranged between 1 and 5 days. Intra-operative complications occurred in one horse. No post-operative complications were recorded. Follow-up information was available for 21 horses (range 1-8 years). Urethral dilation via PU may be a viable option for cystolith removal in male horses.

Interface-mediated protein aggregation

The aggregation of proteins at interfaces has significant roles and can also lead to dysfunction of different physiological processes. The interfacial effects on the assembly and aggregation of biopolymers are not only crucial for a comprehensive understanding of protein biological functions, but also hold great potential for advancing the state-of-the-art applications of biopolymer materials. Recently, there has been remarkable progress in a collaborative context, as we strive to gain control over complex interfacial assembly structures of biopolymers. These biopolymer structures range from the nanoscale to mesoscale and even macroscale, and are attained through the rational design of interactions between biological building blocks and surfaces/interfaces. This review spotlights the recent advancements in interface-mediated assembly and properties of biopolymer materials. Initially, we introduce the solid-liquid interface (SIL)-mediated biopolymer assembly that includes the inorganic crystalline template effect and protein self-adoptive deposition through phase transition. Next, we display the advancement of biopolymer assembly instigated by the air-water interface (AWI) that acts as an energy conversion station. Lastly, we discuss succinctly the assembly of biopolymers at the liquid-liquid interface (LLI) along with their applications. It is our hope that this overview will stimulate the integration and progression of the science of interfacial assembled biopolymer materials and surfaces/interfaces.

Outcomes of Urethroplasty for Synchronous Anterior Urethral Stricture Utilizing the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System

OBJECTIVE

To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort.

METHODS

Data were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups.

RESULTS

One thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6 cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P = .3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P = .003, S2a, P = .001, S2b, P = .01 and S2c, P = .02 and E classifications: E3a, P = .004 and E6, P = .03, were associated with increased odds of functional failure.

CONCLUSION

Repair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.

De- and recellularized urethral reconstruction with autologous buccal mucosal cells implanted in an ovine animal model

OBJECTIVES

Patients with urethral stricture due to any type of trauma, hypospadias or gender dysphoria suffer immensely from impaired capacity to urinate and are in need of a new functional urethra. Tissue engineering with decellularization of a donated organ recellularized with cells from the recipient patient has emerged as a promising alternative of advanced therapy medicinal products. The aim of this pilot study was to develop an ovine model of urethral transplantation and to produce an individualized urethra graft to show proof of function in vivo.

METHODS

Donated urethras from ram abattoir waste were decellularized and further recellularized with autologous buccal mucosa epithelial cells excised from the recipient ram and expanded in vitro. The individualized urethral grafts were implanted by reconstructive surgery in rams replacing 2.5 ± 0.5 cm of the native penile urethra.

RESULTS

After surgery optimization, three ram had the tissue engineered urethra implanted for one month and two out of three showed a partially regenerated epithelium.

CONCLUSIONS

Further adjustments of the model are needed to achieve a satisfactory proof-of-concept; however, we interpret these findings as a proof of principle and a possible path to develop a functional tissue engineered urethral graft with de- and recellularization and regeneration in vivo after transplantation.

Extracellular matrix stiffness aggravates urethral stricture through Igfbp3/Smad pathway

Urethral stricture refers to the narrowing of the urethral lumen. While previous studies have hinted at inflammation as the initial driver of this condition, the reasons and mechanisms behind its progression remain largely unknown. By Atomic force microscope (AFM), researchers measured the matrix stiffness of urethra to be 5.23 ± 0.37 kPa for normal tissue and 41.59 ± 2.48 kPa for stricture urethral scar. Similar results were observed in rat urethral stricture models, where the matrix stiffness of normal urethra was 4.29 ± 0.82 kPa, while 32.94 ± 7.12 kPa for urethral stricture scar. Notably, the matrix stiffness increased in rat models over time. To further investigate, polyacrylamide hydrogels were employed to mimic different levels of stiffness for normal and stricture condition. Interestingly, higher matrix stiffness led to an increased fibroblast-to-myofibroblast transition (FMT) in rat urethral fibroblasts, indicated by enhanced expression of α-SMA and Collagen I, as well as changing in the morphology of fibroblast. RNA-seq analysis suggested that Igfbp3/Smads might regulate the progressive FMT in urethral stricture. In the experiment where the expression of Igfbp3 was inhibited, increasing matrix stiffness lose the potential to stimulate FMT progression and the expression of p-Smad2/3 decreased. On the contrary, overexpression of Igfbp3 promoted the process of FMT in urethral fibroblasts. In conclusion, Igfbp3/Smad pathway appeared to be involved in the progression of urethral fibrosis. This finding suggested that Igfbp3/Smad might be an promising target for future research and treatment in this filed.

Biological Macromolecule-Based Scaffolds for Urethra Reconstruction

Urethral reconstruction strategies are limited with many associated drawbacks. In this context, the main challenge is the unavailability of a suitable tissue that can endure urine exposure. However, most of the used tissues in clinical practices are non-specialized grafts that finally fail to prevent urine leakage. Tissue engineering has offered novel solutions to address this dilemma. In this technology, scaffolding biomaterials characteristics are of prime importance. Biological macromolecules are naturally derived polymers that have been extensively studied for various tissue engineering applications. This review discusses the recent advances, applications, and challenges of biological macromolecule-based scaffolds in urethral reconstruction.

Development of a Wound-Healing Protocol for In Vitro Evaluation of Urothelial Cell Growth

Urethral healing is plagued by strictures, impacting quality of life and medical costs. Various growth factors (GFs) have shown promise as therapeutic approaches to improve healing, but there is no protocol for in vitro comparison between GFs. This study focuses the development of a biomimetic in vitro urothelial healing assay designed to mimic early in vivo healing, followed by an evaluation of urothelial cell growth in response to GFs.

METHODS

Wound-healing assays were developed with human urothelial cells and used to compared six GFs (EGF, FGF-2, IGF-1, PDGF, TGF-β1, and VEGF) at three concentrations (1 ng/mL, 10 ng/mL, and 100 ng/mL) over a 48 h period. A commercial GF-containing medium (EGF, TGF-α, KGF, and Extract P) and a GF-free medium were used as controls.

RESULTS

There was a statistically significant increase in cell growth for IGF-1 at 10 and 100 ng/mL compared to both controls (p < 0.05). There was a statistically significant increase in cell growth for EGF at all concentrations compared to the GF-free medium control (p < 0.05).

CONCLUSION

This study shows the development of a clinically relevant wound-healing assay to evaluate urothelial cell growth. It is the first to compare GFs for future use in reconstructive techniques to improve urethral healing.

Economic evaluation of Optilume, a drug-coated balloon for recurrent anterior male urethral stricture

Objectives

We aim to conduct an economic evaluation of the Optilume urethral drug-coated balloon (DCB) compared with endoscopic management for the treatment of recurrent anterior male urethral stricture in England.

Patients and Methods

A cohort Markov model was developed to estimate the costs and savings to the NHS over a 5-year time horizon of adopting Optilume for the treatment of anterior urethral male stricture versus current endoscopic standard of care. A scenario analysis was conducted which compared Optilume to urethroplasty. Probabilistic and deterministic sensitivity analyses were performed to estimate the impact of uncertainties in model parameters.

Results

When compared with current endoscopic standard of care Optilume resulted in an estimated cost saving of £2502 per patient if introduced in the NHS for the treatment of recurrent anterior male urethral stricture. In the scenario analysis, the use of Optilume compared with urethroplasty resulted in an estimated cost saving of £243. Results were robust to changes in individual input parameters as demonstrated in the deterministic sensitivity analyses, with the monthly probability of symptom recurrence associated with endoscopic management the only exception. Probabilistic sensitivity analysis results demonstrated that Optilume was cost saving in 93.4% of model iterations, when running 1000 iterations.

Conclusion

Our analysis suggests that the Optilume urethral DCB treatment can be a cost-saving alternative management option for the treatment of recurrent anterior male urethral stricture within the NHS in England.

Rectifying disorder of extracellular matrix to suppress urethral stricture by protein nanofilm-controlled drug delivery from urinary catheter

Urethral stricture secondary to urethral injury, afflicting both patients and urologists, is initiated by excessive deposition of extracellular matrix in the submucosal and periurethral tissues. Although various anti-fibrotic drugs have been applied to urethral stricture by irrigation or submucosal injection, their clinical feasibility and effectiveness are limited. Here, to target the pathological state of the extracellular matrix, we design a protein-based nanofilm-controlled drug delivery system and assemble it on the catheter. This approach, which integrates excellent anti-biofilm properties with stable and controlled drug delivery for tens of days in one step, ensures optimal efficacy and negligible side effects while preventing biofilm-related infections. In a rabbit model of urethral injury, the anti-fibrotic catheter maintains extracellular matrix homeostasis by reducing fibroblast-derived collagen production and enhancing metalloproteinase 1-induced collagen degradation, resulting in a greater improvement in lumen stenosis than other topical therapies for urethral stricture prevention. Such facilely fabricated biocompatible coating with antibacterial contamination and sustained-drug-release functionality could not only benefit populations at high risk of urethral stricture but also serve as an advanced paradigm for a range of biomedical applications.

A comprehensive review on hydrogel materials in urology: Problems, methods, and new opportunities

Hydrogel materials provide an extremely promising group of materials that can find an increasingly wide range of use in treating urinary system conditions due to their unique properties. The present review describes achievements to date in terms of the use and development prospects of hydrogel materials applications in the treatment and reconstruction of the urinary system organs, which among others include: hydrogel systems of intravesical drug delivery, ureteral stents design, treatment of vesicoureteral reflux, urinary bladder and urethral defects reconstruction, design of modern urinary catheters and also solutions applied in urinary incontinence therapy (Figure 4). In addition, hydrogel materials find increasingly growing applications in the construction of educational simulation models of organs and specific conditions of the urinary system, which enable the education of medical personnel. Numerous research efforts are underway to expand the existing treatment methods and reconstruction of the urinary system based on hydrogel materials. After conducting the further necessary research, many of the innovative solutions developed to date have high application potential.

Comparison of closure versus non-closure of the intraoral buccal mucosa graft site in urethroplasties. A systematic review and meta-analysis

Aim

To assess postoperative oral morbidity through meta-analysis of comparative studies for closure or non-closure of the buccal mucosa graft harvest area in patients undergoing urethroplasty.

Methods

A systematic literature review was conducted in January 2022. Randomized controlled studies were assessed according to the Cochrane collaboration guidelines. Postoperative pain, difficult mouth opening, alteration of oral salivation, perioral numbness, and tolerance of solid and liquid intake results were assessed. Standard mean differences and risk ratios with 95% confidence intervals were estimated for relative risk. Assessment was performed with subgroup analyses according to time points.

Results

This meta-analysis included 373 patients in 7 randomized studies. The oral pain overall pooled effect estimates were investigated for the time points of day 0-1, day 3-7 and months 1-6. According to corrected effect estimates after sensitivity analysis, at the day 0-1 time point, the non-closure group was significantly superior compared to the closure group. But there was no difference at the other time points and in total. The overall pooled effect estimates for difficult mouth opening were investigated at 4 time points (day 1, days 5-7, months 1-3 and months 6). After sensitivity analysis, the overall pooled effect estimates at 6 months were significantly superior for the non-closure group. There were no significant differences between the non-closed and closed groups based on the overall pooled-effect estimates for oral numbness, salivary secretion alteration, and tolerance of liquid and solid food variants.

Conclusion

The non-closure group was more advantageous in terms of oral pain in the early postoperative period. There were no differences between the groups in terms of alteration of salivation, oral numbness and toleration of liquid/solid food. Although the non-closed group seems more advantageous in terms of ease in mouth movements, more studies are needed to prove this.

Combining Transurethral Resection of Fibrous Tissue and Temporary Urethral Stent Insertion Is an Optimal Strategy for Minimally Invasive Treatment of Recurrent and Long Urethral Strictures

This study investigated the optimal strategy for the treatment of chronic recurrent urethral strictures longer than 3 cm, using a temporary urethral stent. Between September 2011 and June 2021, 36 patients with chronic bulbomembranous urethral strictures underwent temporary urethral stent placement. Retrievable self-expandable polymer-coated bulbar urethral stents (BUSs) were placed in 21 patients (group A), and thermo-expandable nickel-titanium alloy urethral stents were placed in 15 patients (group M). Each group was subdivided into those with and without transurethral resection (TUR) of fibrotic scar tissue. The urethral patency rates at 1 year after stent removal were compared between the groups. The patients in group A showed a higher urethral patency maintenance rate at 1 year after stent removal than those in group M (81.0% vs. 40.0%, log rank test p = 0.012). Analysis of subgroups in which TUR was performed due to severe fibrotic scar, showed that the patients in group A showed a significantly higher patency rate than patients in group M (90.9% vs. 44.4%, log rank test p = 0.028). In the treatment of chronic urethral strictures with a long fibrotic scar, temporary BUS combined with TUR of fibrotic tissue seems to be the optimal minimally invasive treatment strategy.

Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

Urethrocystography: a guide for urological surgery?

Urethrocystography remains the gold-standard technique for urethral pathology diagnosis. Nowadays, of the various indications for performing urethrocystography, the most common is due to a clinical suspicion of urethral stricture. Due to the high prevalence of strictures and their substantial impact on a patient's quality of life, the examination must allow the location, exclusion of multifocality, and assessment of the extent of the stricture to influence surgical planning. This article intends to demonstrate that the radiologist's role, by performing and interpreting the modality of urethrocystography, influences and is crucial for the urologic therapeutic decision and that the patients who were submitted to reconstruction by urethroplasty had a better success rate. The authors aim to review the radiological anatomy of the male urethra, discuss the modalities of choice for imaging the urethra (retrograde urethrography and voiding cystourethrography), provide an overview of the different indications for performing the study, examine the different etiologies for urethral strictures, understand the relevance of the different appearances of urethral pathology, and identify the surgical options, especially in the treatment of urethral strictures. Simultaneously, the study exposes cases of urethral trauma, fistulas, diverticulum, and congenital abnormalities.

The application of 3D bioprinting in urological diseases

Urologic diseases are commonly diagnosed health problems affecting people around the world. More than 26 million people suffer from urologic diseases and the annual expenditure was more than 11 billion US dollars. The urologic cancers, like bladder cancer, prostate cancer and kidney cancer are always the leading causes of death worldwide, which account for approximately 22% and 10% of the new cancer cases and death, respectively. Organ transplantation is one of the major clinical treatments for urological diseases like end-stage renal disease and urethral stricture, albeit strongly limited by the availability of matching donor organs. Tissue engineering has been recognized as a highly promising strategy to solve the problems of organ donor shortage by the fabrication of artificial organs/tissue. This includes the prospective technology of three-dimensional (3D) bioprinting, which has been adapted to various cell types and biomaterials to replicate the heterogeneity of urological organs for the investigation of organ transplantation and disease progression. This review discusses various types of 3D bioprinting methodologies and commonly used biomaterials for urological diseases. The literature shows that advances in this field toward the development of functional urological organs or disease models have progressively increased. Although numerous challenges still need to be tackled, like the technical difficulties of replicating the heterogeneity of urologic organs and the limited biomaterial choices to recapitulate the complicated extracellular matrix components, it has been proved by numerous studies that 3D bioprinting has the potential to fabricate functional urological organs for clinical transplantation and in vitro disease models.

•

Outline the advantages and characteristics of 3D printing compared with traditional methods for urological diseases.

•

Guide the selection of 3D bioprinting technology and material in urological tissue engineering.

•

Discuss the challenges and future perspectives of 3D bioprinting in urological diseases and clinical translation.

Sources, Selection, and Microenvironmental Preconditioning of Cells for Urethral Tissue Engineering

Urethral stricture is a common urinary tract disorder in men that can be caused by iatrogenic causes, trauma, inflammation, or infection and often requires reconstructive surgery. The current therapeutic approach for complex urethral strictures usually involves reconstruction with autologous tissue from the oral mucosa. With the goal of overcoming the lack of sufficient autologous tissue and donor site morbidity, research over the past two decades has focused on cell-based tissue-engineered substitutes. While the main focus has been on autologous cells from the penile tissue, bladder, and oral cavity, stem cells from sources such as adipose tissue and urine are competing candidates for future urethral regeneration due to their ease of collection, high proliferative capacity, maturation potential, and paracrine function. This review addresses the sources, advantages, and limitations of cells for tissue engineering in the urethra and discusses recent approaches to improve cell survival, growth, and differentiation by mimicking the mechanical and biophysical properties of the extracellular environment.

Urethral Stricture and Urethroplasty Practice in a Teaching Hospital in Anambra, South-Eastern Nigeria

Background

Management of urethral stricture disease remains a challenge in the field of urology. Though several options exist for its management, urethroplasty has proved to give the best outcome.

Methodology

This is a retrospective study of urethral strictures and urethroplasties for 5years spanning from January 2015 to December 2019 at a tertiary teaching hospital in Anambra, South East Nigeria. Data was retrieved from the case notes of all the urethral strictures cases which presented to our facility in these 5 years and analysed using Microsoft Excel.

Results

A total of 186 patients were diagnosed with urethral stricture disease within the 5 years' period. However, only 28 (15.1%) of them had urethroplasty within the period, mostly due to lack of fund. Of those who had urethroplasty, their ages ranged from 4 - 64 years with a median of 29.50 years. Motor vehicular road traffic accident (RTA) was the most common (46.43%) aetiology. Excision and anastomosis was the most common type of urethroplasty performed (71.43%) and the most common complication was stricture recurrence (32.14%).

Conclusion

Though urethroplasty techniques have become more refined, accessibility of care continues to hamper treatment in Sub-Saharan Africa due to socioeconomic issues.

Prospects and Challenges of Electrospun Cell and Drug Delivery Vehicles to Correct Urethral Stricture

Current therapeutic modalities to treat urethral strictures are associated with several challenges and shortcomings. Therefore, significant strides have been made to develop strategies with minimal side effects and the highest therapeutic potential. In this framework, electrospun scaffolds incorporated with various cells or bioactive agents have provided promising vistas to repair urethral defects. Due to the biomimetic nature of these constructs, they can efficiently mimic the native cells’ niches and provide essential microenvironmental cues for the safe transplantation of multiple cell types. Furthermore, these scaffolds are versatile platforms for delivering various drug molecules, growth factors, and nucleic acids. This review discusses the recent progress, applications, and challenges of electrospun scaffolds to deliver cells or bioactive agents during the urethral defect repair process. First, the current status of electrospinning in urethral tissue engineering is presented. Then, the principles of electrospinning in drug and cell delivery applications are reviewed. Finally, the recent preclinical studies are summarized and the current challenges are discussed.

Comparative study between thulium laser and cold knife visual urethrotomy for treatment of short bulbomembranous urethral stricture

INTRODUCTION

The classical way to treat urethral stricture is the direct vision cold knife internal urethrotomy (DVIU). Along with advances in laser technology, laser urethrotomy is widely used, such as neodymium-doped yttrium aluminum garnet, argon, potassium titanyl phosphate, and thulium laser. We aimed to compare thulium laser urethrotomy (TLU) and cold knife visual urethrotomy (CKVU) in terms of short bulbomembranous urethral stricture management.

MATERIALS AND METHODS

This prospective interventional study was conducted for 24 months, from January 2018 to January 2020, on 60 patients with primary short bulbo-membranous urethral stricture who came to the Department of Urology of Al-Azhar University Hospital, New Damietta, Egypt. We divided these patients into 2 age-matched groups; 30 patients treated with CKVU and 30 patients with TLU.

RESULTS

Regarding efficacy, postvoid residual urine volume (PVR) was reduced significantly in both groups (P < .001) after 6 months of follow-up; however, the reduction in TLU was greater than CKVU (P = .008). The improvement of Qmax after 6 months was significant and comparable in both groups. Regarding the quality of life, both groups showed a significant (<0.05) improvement in international prostate symptom score (IPSS) and the Male Sexual Health Questionnaire (MSHQ) scale, without no significant difference between both groups (>0.05). TLU showed a significantly (P = .038) shorter operative duration (24 ± 4.17 min) than CKVU duration (33 ± 4.86 min). Compared with CKVU, TLU was associated with less blood loss during surgery (P = .001), lower recurrence rate (46.7% vs. 19.97%, respectively), and lower frequencies of urethral dilatation (P = .001).

CONCLUSION

TLU is an effective and safe therapy for managing bulbomembranous urethral strictures, with a relatively low recurrence rate. Further investigations of other techniques are recommended to look for the most appropriate procedure to combat the urethral stricture problem.

Long-Term Experience with Balloon Dilation for Short Bulbar and Membranous Urethral Strictures: Establishing a Baseline in the Active Drug Treatment Era

Transurethral balloon dilation (BD) is a minimally invasive treatment for urethral stricture disease (USD) performed primarily or as a recurrence salvage maneuver. With the introduction of drug-coated balloons, we sought to characterize patient outcomes using non-medicated balloons. A retrospective review identified patients who underwent BD from 2007 to 2021. Patient and stricture characteristics were collected. All dilations employed the 24Fr UroMaxTM system. Clinical failure was defined by patient-reported lower urinary tract symptom recurrence or need for further stricture management. Ninety-one patients underwent BD with follow-up median (IQR) 12 (3–40) months. Most (75/91, 82%) had prior treatment for USD (endoscopic 50/91 (55%), 51/91 (56%) urethroplasty) before BD. Recurrence rates did not significantly differ between treatment-naïve and salvage patients (44% vs. 52% (p = 0.55)). Median (IQR) time to failure was 6 (3–13) months. The most common complications were urinary tract infection (8%) and post-operative urinary retention requiring catheterization (3%). Radiation history was noted in 33/91 (36%) with 45% recurrence. Patients without previous radiation had a similar recurrence rate of 52% (p = 0.88). Balloon dilation had minimal complications and overall, 50% recurrence rate, consistent regardless of stricture characteristics, radiation history, or prior treatments. These results represent an important clinical benchmark for comparing outcomes using drug-coated balloons.

The contribution of the immune system to genitourinary fibrosis

Fibrotic diseases of the genitourinary tract are devastating and incompletely understood pathologies. These diseases include urethral and ureteral strictures, retroperitoneal fibrosis, and Peyronie's disease. They can contribute to obstructive uropathy and sexual dysfunction. Poor understanding of the pathophysiology of these diseases severely limits our ability to prevent and treat them. Genitourinary fibrotic diseases likely represent related pathologies that share common underlying mechanisms involving wound healing in response to injury. These diseases share the common feature of extracellular matrix abnormalities-such as collagen deposition, transforming growth factor-β accumulation, and dysregulation of collagen maturation-leading to abnormal tissue stiffness. Given the association of many of these diseases with autoimmunity, a systemic pro-inflammatory state likely contributes to their associated fibrogenesis. Herein, we explore the immunologic contribution to fibrogenesis in several fibrotic diseases of the genitourinary system. Better understanding how the immune system contributes to fibrosis in these diseases may improve prevention and therapeutic strategies and elucidate the functions of immunologic contributors to fibrosis in general.

Buccal mucosal graft urethroplasty for anterior urethral stricture, experience from a low-income country

Background/purpose

This study was conducted to present our experience in urethral mucosal graft urethroplasty to repair urethral stricture, as the first experience in our context.

Methods

This is a prospective hospital-based study that had been designed to review management outcomes of buccal mucosal graft urethroplasty for anterior urethral stricture from January 2017 to January 2019.

Results

The total number of involved patients was 60. The success rate was found to be 90% (n = 54), while 6 (10%) had a recurrence of stricture. Pain and pain combined bleeding from internal suture lines were the only early complication encountered in 50 (83.3%) and 2 (3.3%) patients, respectively. late complications occurred as follows 14 (23.3%) patients had UTI, 12 (20%) had wound infections, 8 (13.3%) had changes in ejaculation, and decrease in intensity of orgasm, and 6 (10%) had erectile dysfunction. One of the long-term complications was graft diverticulum in one case and was treated conservatively (in ventral on lay BMG).

Conclusion

Improvement of the service in limited resources countries like Sudan and was reflected in the excellent outcome of BMG urethroplasty as treatment of anterior urethral stricture (success rate 90%).

Double-Modified Bacterial Cellulose/Soy Protein Isolate Composites by Laser Hole Forming and Selective Oxidation Used for Urethral Repair

In this study, a double-modified bacterial cellulose/soybean protein isolate (DMBC/SPI), a new type of urethral tissue engineering scaffold with good biocompatibility, biodegradability, and cell-oriented growth, was prepared. Bacterial cellulose (BC) was physically and chemically modified by laser hole forming and selective oxidation to obtain the double-modified bacterial cellulose (DMBC). The soybean protein isolate (SPI) was compounded on DMBC to obtain DMBC/SPI with better biocompatibility. DMBC/SPI was used to repair the damaged urethra in rabbits. The results showed that DMBC/SPI was beneficial to heal the damaged urethra and did not cause a milder inflammatory response. The repaired urethra was smooth and continuous. DMBC/SPI has a good urethral repair effect and is expected to be used as a new urethral reconstruction material in clinical applications. In addition, FT-IR spectroscopy, SEM, static contact angle measurements, mechanical property investigation, and cell experiments were also performed to characterize the properties of DMBC/SPI composites.

Management of men with ultra-short penile urethral stricture using augmented anastomotic penile skin flap urethroplasty; a retrospective analysis

Background

The management of short anterior urethral stricture is challenging. Our study aims to evaluate the outcome of augmented anastomotic urethroplasty (AAU) for the management of men with ultra-short penile urethral stricture, and to compare it with the dorsal onlay buccal mucosa graft.

Methods

Databases of two tertiary referral centres were retrospectively reviewed to retrieve data of men with ultra-short penile urethral stricture who underwent urethroplasty from 2013 to 2020. Patients who underwent AAU with ventral onlay pedicled skin flap were considered the study group, while patients treated with the dorsal onlay graft augmentation were included as controls. Surgical outcomes included urethral patency, improvement in the maximum flow rate (Qmax), change in sexual satisfaction, and any reported complications.

Results

Thirty-four patients (and 30 controls) with a median age of 26–27 years were included in the study. The maximum flow rate improved significantly in both groups compared to the preoperative value (p < 0.001). The success rate was 88% in the study group compared to 76.7% in the control group. There was no statistically significant difference in the frequency of postoperative penile curvature nor the ventral sacculation between the two groups (p = 0.788 and 0.913). The operative time was statistically significantly longer in the control group (p = 0.044), while the frequency of postoperative void dripping was much higher in the study group (p = 0.007).

Conclusion

The success rate and complications of AAU for men with ultra-short penile urethral stricture were comparable to the dorsal buccal graft.

Efficacy of Mitomycin C Combined with Direct Vision Internal Urethrotomy for Urethral Strictures: A Systematic Review and Meta-Analysis

BACKGROUND

The high recurrence of a urethral stricture after direct vision internal urethrotomy (DVIU) has been a problem for years. Mitomycin C (MMC) is an excellent antifibrosis antigen that has been used in many fields, but its effect on a urethral stricture remains controversial. The purpose of this review was to investigate the effectiveness of MMC in reducing the recurrence rate of a urethral stricture after the first urethrotomy.

METHODS

Common databases were searched for publications prior to November 30, 2020. Randomized controlled and cohort trials were all included. Recurrence and success rates after the first urethrotomy of the posterior urethra were the main outcomes. Revman 5.3 was used for statistical analysis. Two evaluation systems, the Cochrane risk of bias tool and the Newcastle Ottawa Scale, were used to examine the risk of bias for RCTs and all studies. The quality of evidence was assessed by the Grading of Recommendations, Assessment, Development, and Evaluation standard.

RESULTS

Sixteen trials were included, the reporting quality of which was generally poor, and the evidence level was very low to moderate. The addition of MMC could significantly reduce the recurrence rate of urethral strictures (risk ratio [RR] = 0.42; 95% confidence interval [CI]: 0.26, 0.67; p = 0.0002; 9 trials; 550 participants). The results of the subgroup analysis suggested that the effect of MMC combined with DVIU was significant in short (≤2 cm) anterior urethral strictures (RR = 0.39; 95% CI: 0.20, 0.78; p = 0.008), >12-month follow-up (RR = 0.45; 95% CI: 0.26, 0.76; p = 0.003). It also increased the success rate of the first urethrotomy procedure for posterior urethral contracture (RR = 0.74; 95% CI: 0.65, 0.84; p < 0.00001; 7 trials; 342 participants). Low-dose local injection of MMC was the most commonly used method.

CONCLUSION

MMC combined with DVIU is a promising way to reduce the long-term recurrence rate of a short-segment anterior urethral stricture. It also increases the success rate of the first urethrotomy of the posterior urethra. However, more high-quality randomized controlled trials are needed.

A Primary Urothelial Carcinoma Presenting as a Mid-Bulbar Urethral Stricture in a 30-Year-Old Male

The bulbar urethra is the most common site of anterior urethral strictures. In this case report, we present a 30-year-old male who was referred to us as a case of mid-bulbar urethral stricture. Urethroplasty was booked and a papillary lesion was found on routine diagnostic cystoscopy. An open biopsy was taken which showed invasive high-grade papillary urothelial carcinoma with squamous differentiation. This case is rare in terms of a young age of incidence, a lack of risk factors, an absence of suspicious symptoms, and a short duration of signs and symptoms. Urologists should consider workup for malignancy even in young patients who present with an idiopathic urethral stricture and a short duration of symptoms.

Long-term outcome of Non-Transecting Anastomotic Bulbar Urethroplasty for Urethral Strictures: An 8-year experience from Liaquat National Hospital Karachi

Objectives

To determine the long-term outcome and complications of non-transecting anastomotic bulbar urethroplasty for the treatment of small bulbar urethral strictures presenting at Liaquat National Hospital, Karachi.

Methods

This interventional study was conducted from January 2012 to December 2019 with the study duration of eight year at Liaquat National Hospital, Karachi. All patients presenting in the outpatient department with urethral strictures were included in the study. Patients were evaluated postoperatively for complications and outcomes were determined. The data was analyzed using SPSS v.25.

Results

A total of 358 patients were treated with non-transecting anastomotic bulbar urethroplasty during this 8-years period. The most common site of stricture formation was bulbar urethra 186 (50%), followed by bulbo-membranous urethra; 103 (31%), and bulbo-penile urethra; 69 (19%). The mean stricture was 1.2 cm (0.5-2.5 cm) in length. The main postoperative complications were scrotal swelling in 7 (1.9%), wound infection in 6 (1.6%), wound dehiscence in 3 (0.8%), and transient sexual dysfunction in 31 (8.6%) patients with an overall initial success rate of 97.8%. No permanent deficit in sexual function was reported.

Conclusions

Non-transecting anastomotic bulbar urethroplasty has a good outcome with insignificant postoperative complications in patients with small bulbar urethral stricture disease.

Mesenchymal Stem Cell-Derived Exosomes Induced by IL-1β Attenuate Urethral Stricture Through Let-7c/PAK1/NF-κB-Regulated Macrophage M2 Polarization

Background

Urethral stricture is a clinical challenge for both patients and clinicians. Post-traumatic urethral stricture is associated with formation of scar tissue caused by excessive inflammation. The aim of this study is exploring potential therapeutic strategies for this condition.

Methods

In vivo experiments on New Zealand rabbits and in vitro experiments on THP-1 monocytes and urethral fibroblasts were performed to investigate the effects on post-traumatic urethral stricture of exosomes isolated from IL-1β-treated mesenchymal stem cells (Exo-MSCs^IL-1β) and the role of macrophage M2 polarization in this process. Additionally, related signaling and mechanism behind were explored.

Results

In a New Zealand rabbit model of post-traumatic urethral stricture, injection of Exo-MSCs^IL-1β significantly reduced urethral stricture and collagen fiber accumulation compared with Exo-MSCs. Addition of Exo-MSCs^IL-1β to THP-1 monocytes in vitro induced M2 macrophage polarization, which, in turn, inhibited activation of urethral fibroblasts and synthesis of collagen. Mechanistically, Exo-MSCs^IL-1β were found to contain high levels of the microRNA let-7c, and luciferase reporter assays showed that let-7c interacted with the 3'UTR of PAK1 mRNA. Transfection of THP-1 cells with a let-7c mimic downregulated PAK1 expression and inhibited activation of the NF-κB signaling pathway.

Conclusion

These results support a role for let-7c-containing Exo-MSCs^IL-1β in reducing urethral stricture via inhibition of PAK1-NF-κB signaling, M2 macrophage polarization, and differentiation of urethral myofibroblasts.

Gel Casting as an Approach for Tissue Engineering of Multilayered Tubular Structures

Several urological structures, such as the male urethra, have a tubular organization consisting of different layers. However, in severe urethral disease, urologists are limited to replacing solely the epithelial layer. In case of severe hypospadias and urethral stricture disease, the underlying supporting structure (the corpus spongiosum) is either absent or fibrotic, causing suboptimal vascularization and therefore increasing the risk of graft failure. Recapitulating the multilayered architecture of the urethra, including supporting structure with tissue engineering, might minimize urethral graft failure. However, current tissue engineering applications for complex multilayered tubular constructs are limited. We describe a gel casting method to tissue engineer multilayered tubular constructs based on fiber-reinforced cell-laden hydrogels. For this, a multichambered polydimethylsiloxane mold was casted with fiber-reinforced hydrogels containing smooth muscle cells (SMCs) and a coculture of endothelial cells and pericytes. The cell-loaded hydrogels were rolled, with the fiber mesh as guidance, into a tubular construct. In the lumen, urothelial cells were seeded and survived for 2 weeks. In the tubular construct, the cells showed good viability and functionality: endothelial cells formed capillary-like structures supported by pericytes and SMCs expressed elastin. With a graft produced by this technique, supported with subepithelial vascularization, urethral reconstructive surgery can be improved. This approach toward tissue engineering of multilayered tubular structures can also be applied to other multilayered tubular structures found in the human body. Impact Statement Recapitulating the multilayered architecture of tubular structures found in the human body might minimize graft failure. Current tissue engineering applications for complex multilayered tubular constructs are limited. Here we describe a gel casting approach based on fiber-reinforced cell-laden hydrogels. A multichambered polydimethylsiloxane mold was casted with cell-loaded, fiber-reinforced hydrogels, with the fiber mesh as guidance, into a tubular construct. A graft produced by this technique can improve reconstructive surgery by providing subepithelial vascularization and thereby can reduce graft failure.

Recurrent Anterior Urethral Stricture: Challenges and Solutions

Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.

The pre-operative and post-operative imaging appearances of urethral strictures and surgical techniques

Urethral strictures arise from a variety of etiologies, most commonly either iatrogenic or inflammatory in the anterior urethra and iatrogenic/surgical or traumatic etiologies in the posterior urethra. Diagnosis and treatment planning depend on urethrography, usually performed with a combination of retrograde urethrography (RUG) and voiding cystourethrography (VCUG) to evaluate the anterior and posterior urethra, respectively. While this is most commonly performed fluoroscopically, sonographic urethrography is an alternative, although at the expense of the posterior urethra, it is only visualized using a transrectal approach. In addition to understand urethral anatomy, familiarity with normal periurethral structures is necessary to avoid misdiagnosis, such as Cowper's ducts, the glands of Littré, and the prostatic and ejaculatory ducts. Surgical management depends on the stricture location, length, and number and options range from balloon dilatation to endoscopic urethrotomy to anastomotic and substitution urethrotomy. Postprocedural management includes urethrography to identify potential complications including urethral leak, graft failure, and stricture recurrence.

The long-term outcome of urethrotomy for primary urethral strictures: a population-based analysis

OBJECTIVE

To determine the long-term outcome of endoscopic urethrotomy for primary urethral strictures based on a population-based approach.

PATIENTS AND METHODS

We analysed a nationwide database of all patients with urethral stricture disease who underwent endoscopic urethrotomy as a primary intervention between January 2006 and December 2007. All patients were followed individually for 7-9 years. Frequencies and types of surgical re-interventions were documented. Repeat surgical interventions were stratified into three treatment types: urethrotomy, urethroplasty, and end-to-end urethral anastomosis.

RESULTS

A total of 1203 men underwent urethrotomy during the index period. The median (SD, range) patient age was 63 (15.7, 20-85) years. A total of 136 patients (11%) died during follow-up. Within the follow-up period, 932 patients (78%) received no further surgical re-intervention for recurrent disease, and 176 patients (14.6%) required one, 53 (4.5%) two, and 41 (3.4%) three or more procedures. The mean number of re-interventions was 1.5/patient and the lowest re-intervention rate was in patients aged ≥80 years (13.9%). In 236 cases (68%) at least one repeat urethrotomy was performed. An open reconstruction was performed in 87 cases (32%), with urethroplasty in 21 patients (24%), and end-to-end anastomosis in 66 patients (76%). The mean interval until re-intervention was 29.5 months.

CONCLUSIONS

This long-term population-based study suggests that the invasive re-treatment rate in men following initial urethrotomy is 22% within 8 years and lowest in the advanced age cohort.

Management of Recurrent Urethral Strictures: A Therapeutic Challenge

Urethral stricture disease is relatively common, and its management remains a therapeutic challenge for urologists despite recent advancements in endoscopic and reconstructive surgery. The majority of the strictures are acquired from injury or infection. Urethral stent implantation, a minimally invasive procedure, can be safely and effectively used as a primary surgical procedure in treating recurrent urethral stricture. Herein, we present a case of a 43-year-old male patient with complaints of intermittent urination, oliguria, and incomplete voiding with urinary frequency. Further urological investigations, a uroflowmetry, and a urethrogram were carried out. Oliguria, along with a mid-bulbar urethral stricture at the previous excision anastomotic site, was diagnosed. Despite a higher success rate of urethroplasty and temporary stent placement, urethral stricture recurrences are still an occurring entity. No definite therapeutic strategy has been adopted to evaluate and approach the morbidity effectively. Implementation of an effective primary procedure with minimally based complications should be generated to avoid future stricture recurrences. Larger-scale studies involving urethral stricture patients can gather sufficient data to obtain a complete curative treatment option for the future.

Urethral Complications While Using 26F vs 28F Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate: A Retrospective Observational Study

Objective: To determine the rate of the urethral stricture (US) and bladder neck contracture (BNC) between patients who undergo Holmium Laser Enucleation of Prostate (HoLEP) surgery with 26F vs 28F resectoscope sheaths (RS). Studies report rates of 2.8-4.4% and 3.6-5.4% for US and BNC, respectively. To date, there are no studies that have shown the difference between RS size and urethral complications. Methods: We retrospectively reviewed charts of patients who had HoLEP surgery between August 2015 and June 2018, by a single surgeon. Those with a prior history of US or BNC were excluded. The operative set-up for an HoLEP includes Ho:YAG laser, urethral dilation, a 26F or 28F continuous flow RS, and a tissue morcellator. Primary endpoints include postoperative US or BNC. Secondary endpoints include postoperative catheterization time, success of voiding trial, and urinary incontinence. Statistical analysis was performed by using appropriate methods. Results: Out of 502 HoLEP patients, 339 consecutive patients had surgery with a 28F RS (Group A) and 163 consecutive patients had surgery with a 26F RS (Group B). Twelve patients (A) and three patients (B) had post-op US (p = 0.41). Eight (A) and zero (B) patients had post-op BNC (p = 0.0585). Stress urinary incontinence at 6 weeks, 3-6 months, and 1 year was present in 15.9% (both A & B), 6.5% (A) vs 6.1% (B) (p = 0.88), and 3.2% (A) vs 1.8% (B) (p = 0.564), respectively. Both blood loss and change in hemoglobin were higher in the 28F group with no significant difference in rate of transfusion. Conclusions: RS size had no impact on the rate of US or BNC; however, there was lower incidence in the 26F sheath cohort for both. The 28F sheath had a larger change in hemoglobin levels and estimated blood loss, but the higher rate of transfusion was not statistically significant. There was no difference in the stress incontinence rates, length of stay, and enucleation rates.

A prospective, multi-center, open-label, single-arm phase 2b study of autologous adult live cultured buccal epithelial cells (AALBEC) in the treatment of bulbar urethral stricture

PURPOSE

To evaluate the safety and efficacy of autologous adult live cultured buccal epithelial cells (AALBEC) in treatment and management of bulbar urethral stricture in men.

METHODS

This was a prospective, multi-center, open-label, single-arm phase 2b study. A total of 18 male patients with bulbar urethral stricture of at least 1 - 4 cm in length were enrolled in the study. All 16 patients had AALBEC implanted and were included in the safety set. Change in total American Urology Association (AUA) symptom score, urinary flow rates assessed by uroflowmetry and a requirement for surgery after 24 weeks from baseline were determined in patients. Data of treatment efficacy were analyzed.

RESULTS

The AUA score at baseline was 21 (3.9) that showed a statistically significant reduction starting from week 2 [8 (4.4), p = 0.0001] which sustained until week 24 [2 (1.2), p = 0.0005]. Overall mean total AUA symptom score was reduced by 90.5% after the treatment. Significant reductions from baseline at week-24 were also observed in voiding time (92.5 (47.3) vs. 51.9 (17.4) s, p = 0.0046) and flow time [86.9 (48.2) vs. 47.9 (19.6) s, p = 0.0052]. All patients showed absence of any significant adverse events.

CONCLUSION

Significant improvement was seen in the AUA symptom score and uroflowmetry parameters and no patients required surgery during 24 weeks post-treatment. It can be concluded that AALBEC is a safe and effective treatment for bulbar urethral stricture of 1 - 4 cm length to improve the quality of life and the physiological function of urethra.

Frequency of Extravasation on Pericatheter Retrograde Urethrogram in Patients Who Undergo Posterior Urethroplasty

Introduction

Urethroplasty is the gold standard treatment for urethral stricture disease resulting from pelvic fractures, urethral manipulation, and straddle injuries. Post-operative morbidity depends on the presence of urethral catheterization with or without a suprapubic catheter (SPC). Urethral healing at the anastomotic site can be easily assessed using retrograde pericatheter urethrography (RPU). Post-operative removal of the catheter is traditionally performed on the 21^st day following urethroplasty. However, some controversy still exists regarding the best feasible time of proper urethral healing and its assessment utilizing simple techniques. The duration of anastomotic healing differs depending on the type of procedure performed, but whether there is any significant difference in duration of healing at the anastomotic site according to the etiology of short‐segment stricture urethra is still a dilemma.

Materials and methods

This was a descriptive case-series conducted for a duration of six months from September 2019 to February 2020 at the urology department of a tertiary care hospital in Karachi, Pakistan. A sample population of 135 patients aged 20-50 years with posterior urethral stricture who underwent posterior urethroplasty with disease duration of >12 months was included in the study. All patients were put on the next operation theater (OT) list for urethroplasty. After surgery, the patients were catheterized and were kept in the ward under observation for 48 hours and discharged on the 2^nd post-operative day. All patients were followed weekly and RPU was performed on the 21^st day following urethroplasty to assess the presence of extravasation and the collected data was entered into the proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0.

Results

The mean age of our participants was 32.8±6.02 years. The mean duration of the procedure was 26.3±7.14 months. Extravasation cases were observed in less than one-fifth (n=22 out of 135, 16.3%) of the posterior urethral stricture patients in our study.

Conclusions

It is to be concluded that extravasation is fairly common in patients who undergo posterior urethroplasty. The prevalence varies depending on the assessment method, likely reflecting the treatment of somatic symptoms.

Larger patients shouldn't have fewer options: urethroplasty is safe in the obese

Objective

To examine the impact of obesity on perioperative outcomes and urethral stricture recurrence after anterior urethroplasty.

Material and Methods

We reviewed our prospectively maintained single-surgeon database to identify men with anterior urethral strictures who had undergone anastomotic or augmentation urethroplasty between October 2012 and March 2018. In all, 210 patients were included for primary analysis of perioperative outcomes, while 193 patients with at least 12 months follow-up were included for secondary analysis of stricture recurrence. Patients grouped by BMI were compared using univariate and multivariate analyses for perioperative outcomes and log rank testing for recurrence-free survival.

Results

Overall, 41% (n=86) of patients were obese and 58.6% (n=123) had bulbar urethral strictures. Obese patients had significantly longer urethral strictures (mean=6.7cm±4.7) than nonobese patients (p <0.001). Though urethroplasty in obese patients was associated with increased estimated blood loss (EBL) relative to normal BMI patients on both univariate (p=0.003) and multivariate (p <0.001) analyses, there was no difference in operative time, length of stay, or complication rate between BMI groups. At a mean follow-up interval of 36.7 months, 15% (n=29) of patients had stricture recurrence, yet recurrence-free survival was not significantly different between groups (log rank p=0.299). Dorsal augmentation urethroplasty resulted in significantly fewer recurrences in obese patients compared to nonobese patients (p=0.036).

Conclusion

Despite the association with increased urethral stricture length and EBL, obesity is not predictive of adverse perioperative outcomes or stricture recurrence. Obese patients should be offered urethral reconstruction, but patient selection and preoperative counseling remain imperative.

Patient-reported outcomes after buccal mucosal graft urethroplasty for bulbar urethral strictures: results of a prospective single-centre cohort study

OBJECTIVES

To describe patient-reported outcome measures (PROMs) after buccal mucosa graft (BMG) urethroplasty.

MATERIALS AND METHODS

We prospectively collected PROMs in patients who underwent BMG urethroplasty for bulbar urethral strictures between October 2009 and February 2017. Preoperatively and at the first, second and third postoperative follow-up visits, patients completed five PROM questionnaires: the International Prostate Symptom Score (IPSS); the IPSS Quality of Life questionnaire; the Urogenital Distress Inventory Short-Form questionnaire (UDI-6); the International Index of Erectile Function (IIEF)-5 questionnaire, combined with IIEF-Q9 and IIEF-Q10 for assessing ejaculatory and orgasmic functions; and the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) questionnaire. In addition to using these questionnaires, we evaluated maximum urinary flow rate (Q_max ), post-void residual urine volume and total voided urine volume at each follow-up visit. Buccal pain and discomfort were assessed using a visual analogue scale (VAS). Comparison of questionnaire scores was performed using a paired Wilcoxon rank-sum test. Treatment failure was defined as any need for urinary diversion or urethral instrumentation after surgery.

RESULTS

A total of 97 patients met the inclusion criteria. The first postoperative follow-up visit was at a median of 2.1 months (n = 97/97), and the second and third visits were after a median of 7.8 (n = 82/97) and 17.0 months (n = 70/97), respectively. Significant improvements compared to baseline were observed in IPSS, and IPSS-QOL, UDI-6 and ICIQ-LUTS-QOL scores at the first follow-up, and remained improved during the follow-up period (P ≤ 0.001). Patients with mild to no baseline erectile dysfunction experienced a significant decline in erectile function at the first follow-up (median [interquartile range {IQR}] preoperative IIEF-5 score 23.0 [21.0-25.0] vs median [IQR] IIEF-5 score at first follow-up 19.5 [16.0-23.8]; P ≤ 0.001). This decline fully recovered during further follow-up (median [IQR] IIEF-5 score at third follow-up 24.0 [20.5-25.0]; P = 0.86). No significant changes in median orgasmic and ejaculatory function were noted. The first postoperative median (IQR) VAS score was 3.0 (2.0-4.45), and a significant improvement in local pain and discomfort was observed during the follow-up (median [IQR] VAS at third follow-up: 0.0 [0.0-1.0]; P ≤ 0.001). Nine patients (9/97; 9.3%) had treatment failure. Stratifying recurrence based on a difference of <10 mL/s vs ≥10 mL/s between preoperative and postoperative Q_max could not demonstrate a significant difference (P = 0.06).

CONCLUSION

Significant improvements in voiding symptoms and quality of life after surgery were reported. Patients with good baseline erections recovered erectile function during follow-up, although a significant decrease in erectile function was observed at the first follow-up. This study highlights the importance of PROMs in urethral reconstructive surgery, emphasizing that success should not be defined only by stricture-free survival.